Healthcare Provider Details

I. General information

NPI: 1750860318
Provider Name (Legal Business Name): GENINE MARIE GORMAN PHD, MSN, BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 CENTRAL AVE
PEARL HARBOR HI
96860-4908
US

IV. Provider business mailing address

480 CENTRAL AVE
PEARL HARBOR HI
96860-4908
US

V. Phone/Fax

Practice location:
  • Phone: 808-474-4242
  • Fax: 808-474-0918
Mailing address:
  • Phone: 808-474-4242
  • Fax: 808-471-0918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number44764
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number44764
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: